Fauci argues for an organized approach to bioethics, and to the fight against disease in the developing world.

Question: Where are we? 

Anthony Fauci: Well the big issues are the whole issue of global peace. I think that’s one of the most important thing. I’m a scientist and a physician, and that’s not my area; but it just seems to me that the destruction, and the death, and the threat, and the insecurity that goes along with people who are ideologically at such odds that it leads to destruction, and death, and killing. To me, that is a major issue.

I’m sure there will always be wars; but I think we need to try as best as we can to understand what it is about people who are such at odds with us that they wish us harm; as well as analyze are we doing anything ourselves that are putting us at such odds with other people that we’re instigating this clash of cultures.

It’s no news to anybody. You just pick up the newspaper any day, you see another example of conflict throughout the world. And that’s something that we’ve got to pay a lot of attention to and do what we can, be it the Middle East problems, or the Israel-Palestine, Iraq-Iran, other nations. The Cold War which then warmed up, which is now getting back to a cold war. It’s kind of discouraging. 

Well actually bioethics is a very, very important field. As we get more and more in the arena of understanding science and getting better opportunities, the fact that you can do things with biological sciences that have an impact on a human being means you must have ethical standards. And paramount among these are when you do something that involves a human subject.

There are a lot of bioethical issues, but for example, if you’re trying to develop a new drug or a new vaccine, and you need to do experimentation, there has to be some fundamental, immutable principles of ethics that guide what you can and cannot do when you’re dealing with another human being. And there are also fundamental things that you can and cannot do when you’re dealing with life itself.

Is it or is it not ethical to create an embryo, and to create a person for the purpose of getting an organ to give to someone else? Your knee-jerk reaction is absolutely not; but you need the ethical analysis of that to show why and how that is something that you need to stay away from.

I think that bioethics is one of the most important, evolving fields that we have. Because, as science gets more and more sophisticated, and as the opportunities for transforming biological sciences occur, we’re going to be faced with more and more important ethical questions. And we can’t approach that by the seat of our pants. We have to have experts who study that and make that a career of analyzing the kinds of ethical issues and gaining experience so that when people come in, and they’re faced with a question of ethics in the biological sciences, at least you have a cadger of people who pay serious attention to that.

Well the important issues in global health are the fact that there are situations in the world where people are dying from diseases that are imminently preventable if we do the right public health measures. That is complicated, and this is one of the reasons why I find public health, in many respects, so invigorating and exciting. Because if it was just public health in a vacuum, it would be relatively easy. But it’s public health intertwined with poverty, disenfranchisement, wars, lack of leadership, environmental cataclysmic issues like tsunamis and earthquakes, and things like that. 

We’re living in a world where, if you’re in the United States or in the U.K. or Canada, there are diseases that you don’t even think about because they don’t have any impact. You’re vaccinated against them. If you get sick, you get an antibiotic. The environment is not threatening, like malarias and mosquitoes and things like that.

Then you go into Sub Saharan Africa and you see things that are unthinkable – 1.3 million people dying every year of malaria, more than a million of which are less than five years old, many of which are less than one year old; one point six million people dying of tuberculosis; ______ diseases and respiratory diseases ravishing populations. These are things that can be prevented.

So to me, one of the most challenging issues that I look at when you talk about global issues and global health is obviously, it isn’t as easy as just bringing medications there. You’ve got to do it at the same time as you build a sustainable infrastructure in the countries involved so that they can ultimately fend for themselves. Going in, treating people for malaria, giving them bed nets, spraying their huts, etc., that’s all good, and that will decrease the whole issue of malaria in certain countries. But what we’ve got to do at the same time is to build what we call a sustainable infrastructure to help the world to get on a much, much more even keel with the developed world; and to prevent literally millions and millions of deaths each year.

To me, that’s the big challenge.

To me, it isn’t easy; but to me, it seems to be easy. And that is to adopt a policy of health diplomacy.

In fact, Governor Tommy Thompson spoke about this just this morning [July 6, 2007], here in Aspen. And that is to make as an important goal that the United States and other developed countries will export global health; will help people in countries who have situations that they cannot handle – vis-à-vis health – but also to help them to build the infrastructure that they will need to sustain it on their own.

And that’s helping to train physicians and healthcare providers; making the incentive for them to stay in their own countries, or return to their own countries after they train here in the United States; help them to do the very simple things like vaccinations and prevention of malaria by simple things like bed nets.

Those are the kinds of things that we need to do. If we engage and put a fraction of the resources that we put into other areas that we put into global health diplomacy, I think not only would it be good for the rest of the world, but the United States will be looked upon in a much more favorable light than it is currently [i.e. 2007] looked upon.

Well I think his [George W. Bush] legacy in health will be very, very positive when it comes to international, global health. I think the combination of the President’s Emergency Plan for AIDS Relief – the PEPFAR Program – and the President’s Malaria Initiative – the PMI – those two things alone, I think, from a health standpoint and from global recognition in the arena of health, will be, in my opinion, the most important, and lasting, and positive legacy of this administration.

Well first of all, for domestic health, the issue that’s crying out to be addressed, and it’s going to take courage on the part of leadership, the President, it’s going to take cooperation with the Congress; it’s going to take an understanding and a flexibility on the part of the American public; is that we must address the fact that in this rich country of ours, we have 40-plus million people without healthcare insurance.

So we’ve got to be able to fix that problem, and fix it reasonably quickly so that when people lose their jobs, and with it lose their health insurance, and find out that they’re one job dismissal away from being completely vulnerable to disease and getting their savings and their family wiped out because they don’t have health insurance--we’ve got to fix that problem.

So if you’re asking me what I would think if the next president were to ask me my opinion, and what I would think from a domestic standpoint what we need to do, we really need to fix the healthcare delivery problem in this country [USA] with regard to universal health access to everyone. It’s not going to be easy, but I think it can be done. I think that if you have a flexible system where people can still have the choice of the doctor that they want, if they have insurance that they are able to pay for.

But that doesn’t mean that you then not allow people who don’t have the wherewithal to have insurance, that everybody has insurance.

And everybody can get a doctor. It may not necessarily be the doctor of your choice, but it’s a doctor that’s well trained and paid well enough to be someone of high quality. So just because you go into a system where you’re assigned a doctor, if you have people who are well trained and well paid, and have good motivations for being in that, you can get good medical care.

You don’t necessarily have to then exclude those people who want to choose their own doctor, and are willing to pay to choose their own doctor. So I think you can get both worlds there.

And also, there’s enough profit margin in drugs and the development of drugs that I don’t think there’s going to be an issue with the drug companies. There’s always going to be the need for new medications, better medications. So I don’t see that as an issue.

Disease in this country, we still have a problem with HIV/AIDS. Right now there are still 40,000 new infections each year in our nation. That has plateaued at 40,000 for the last 14 years. That’s disgraceful. We’ve got to do something about that.

And the CDC [Centers for Disease Control and Prevention] is already going in that direction by making testing for HIV a part of routine healthcare. 

There are a million people who are infected in this country with HIV, at least 25% of which do not know that they are infected. And the much greater majority of those people are the ones that are inadvertently transmitting the infection to others. So we’ve got to get and break that wall, and push down that wall of 40,000 new infections each year from the standpoint of health in this country. That’s, to me, the first thing that we need to do.

Bio-terrorism is a threat. It’s very, very difficult when you have to prepare for something that might not ever happen. So I have been very much involved in the preparedness for bio-defense by developing vaccines, therapeutics, diagnostics for the category A and B agents that are the highest calculated risk by our Homeland Security officials.

And what we’ve done, to try and make that a worthwhile endeavor, is as follows: to use the resources that you would apply to developing these vaccines, and these drugs, and these diagnostics to not only cover infections or microbes that would be deliberately released on the country, but also the broader bio-terrorist. The worst potential bio-terrorist is nature itself.

If you look historically at what’s happened with epidemics, and the influenza pandemic in 1918, the threat of SARS [severe acute respiratory syndrome], the HIV epidemic. So nature does a pretty good job of terrorizing the human civilization.

So if you utilize the resources that you can apply to developing specific countermeasures for agents of high probability of bio-terror, but make that be fungible, as it were, to increasing your capacity to respond to any agent, even those that naturally occur.

So yes it’s a threat. You can never quantitate how great a threat it is. So why not spend the money not only protecting against the threat of deliberate terror, but also the threat of naturally occurring terror?

There is comfort in that literally, as the weeks and months go by, our preparedness against this gets better and better. There certainly is the possibility that there will be a bio-terror attack. If you’re well prepared and you have the counter measures in place, the impact on people will hopefully be minimal.

I don’t think that people need to look upon this as the end of the world, where we would have a bio-terror attack and we all die. The chances of that are so vanishingly small as to be almost not under consideration; but there is the possibility that people could die or get sick from a bio-terror attack. You can mitigate that.  You can lessen the impact of it by doing what we’re literally doing every week and month now. And that is by trying to develop better countermeasures.

Recorded On: July 6, 2007